2Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City (current affiliation)

3School of Pharmacy, University of Wisconsin, Madison

Abstract: Antibiotics are often prescribed to nursing home residents, but studies have shown that many of these agents are prescribed inappropriately, leading to drug-related complications and to increased bacterial resistance, among other concerns. The authors provide an overview of antibiotic stewardship programs and summarize how they tailored one such program to their hospital’s long-term care (LTC) facility. This pharmacist-led team model resulted in an almost 50% reduction of inappropriately prescribed antibiotic use over 3 months. The authors conclude that more research is needed to determine the effect of their antibiotic stewardship program on antibiotic prescribing, resident hospitalization rates, and costs of care. They also note that a comparison of various antibiotic stewardship models employed in nursing homes would be useful to determine best practices in other LTC facilities.

An estimated 1.6 million to 3.8 million nursing home residents are treated for infections annually, and approximately 400,000 infection-related deaths occur in long-term care (LTC) facilities every year.1 According to the Society for Healthcare Epidemiology of America (SHEA), antibiotics constitute up to 40% of all prescribed medications in LTC facilities, with as many as 70% of residents having at least one antibiotic prescription in any given year.2 According to various studies, however, 25% to 75% of the antibiotic use in nursing homes is inappropriate.2,3 This not only puts residents at increased risk of drug-related complications, but because the majority of these residents are elders, adverse effects due to the decreased kidney, liver, and cerebral function that occurs with aging are also more likely.2 In addition, because many LTC residents take several medications daily, they also have an increased likelihood of experiencing drug-drug interactions.2

Another important issue surrounding inappropriate antibiotic use is the development of bacterial resistance. Because LTC residents live in close proximity to one another, there is a greater risk of spreading antibiotic-resistant organisms.2 More complications arise with antibiotic-resistant infections, which make them harder to treat.4 Antibiotic resistance in these patients increases the likelihood of and the need for hospitalization, increasing mortality and cost.4 The Figure illustrates the trend in antibiotic-resistant infections between 2000 and 2004.1 Although these data are more than 8 years old, and no more recent longitudinal data are available, based on our experience, the trend demonstrated by the Figure is increasing.

The effort to improve antibiotic use has been focused primarily in inpatient settings.5-7 Most US hospitals have some type of antibiotic management program, and these have been shown to be an effective tool for combating drug resistance and for improving prescribing practices in hospitals.8,9 However, little progress has been made in implementing such programs in LTC settings. Our successful hospital antibiotic stewardship program led our pharmacy team to seek a way to translate that success to our hospital’s LTC facility.

The Pharmacist’s Role

We reviewed the literature on antibiotic stewardship programs that included pharmacists and that were set in both hospitals and in LTC facilities. We found that studies exploring the effectiveness of antibiotic stewardship initiatives often actively involved pharmacists on the program’s team. In many instances, pharmacists assumed leadership roles, because optimal antibiotic use directly relates to the major objectives of pharmacy practice: safe and effective use of medications and cost-effective care.7

The positive impact of including clinical pharmacists trained in infectious diseases (ID) on antibiotic stewardship teams has been well documented.8-12 One such study compared antibiotic recommendations made by ID pharmacists versus ID fellows.12 Pharmacists in this study were backed up as needed by the ID physician. Recommendations were later evaluated and compared in a blinded manner by the ID physician who directed the antibiotic stewardship program. This study focused on evaluating the appropriateness of therapy, patient outcomes, and cost of hospitalization. The authors found that antibiotic choice was deemed appropriate in 87% of pharmacist recommendations versus 47% of fellow recommendations, with cure rates of 64% and 42%, respectively. The median cost of the hospital stay was $6468 for patients with antibiotic recommendations from the ID pharmacist and $7864 for patients of ID fellows; the median cost of antibiotics was $79 versus $122, respectively.12

The Infectious Diseases Society of America (IDSA) has also recognized the value of the pharmacist’s expertise and recommends the inclusion of these healthcare professionals on antibiotic stewardship teams.6 The guidelines note “Core members of a multidisciplinary antimicrobial stewardship team include an infectious diseases physician and a clinical pharmacist with infectious diseases training (A-II) who should be compensated for their time (A-III), with the inclusion of a clinical microbiologist, an information system specialist, an infection control professional, and hospital epidemiologist being optimal (A-III).”

Antibiotic Stewardship in Long-Term Care Facilities

In contrast, little progress has been made in establishing antibiotic stewardship programs in LTC facilities, despite evidence of the continuing increase in antibiotic resistance in this setting and support for antibiotic stewardship programs from the Centers for Disease Control and Prevention, SHEA, the Association for Professionals in Infection Control and Epidemiology (APIC), the American Society of Health-System Pharmacists, and other healthcare societies.1,13,14

Although the concept has widespread support, developing a viable and effective model of antibiotic stewardship for LTC facilities presents a major challenge. For example, the APIC and SHEA recommendation supporting the implementation of such programs in LTC facilities has an evidence rating of level I B (strong recommendation, moderate evidence), which indicates a paucity of actual practical experience.13

Some of the barriers to implementing antibiotic stewardship programs in nursing homes are the lack of ID physicians and pharmacists, a deficit in knowledge regarding current guidelines, the lack of an antibiogram, and limited pharmacist access to patient records.5

The Memorial Health Center Antibiotic Stewardship Program

The Memorial Health Center Hospital in Medford, WI, has a successful antibiotic stewardship program that is led by pharmacists. Our program consists of a clinical pharmacist with training in ID, supported by an internal medicine physician (as needed), staff pharmacists, and an infection control coordinator. Based on the success and popularity of the program among the hospital physicians, we expanded the program to Memorial Health Center Nursing Home, the LTC facility associated with the hospital. Because the nursing home is owned by the hospital, pharmacists have full access to nursing home patients’ electronic medical records, physicians’ progress notes, laboratory results, and other data. Our goals were as follows: (1) to evaluate the need for antibiotic stewardship; (2) to reduce the inappropriate use of antibiotics; and (3) to determine whether pharmacists could improve antibiotic prescribing practices in the nursing home.

Study Design

Our study was constructed in two phases. The first phase was observational, with the goal of performing a needs assessment. The second phase was interventional and included an evaluation of the efficacy of the antibiotic stewardship program. The head of the pharmacy department at Memorial Health Center approved the study design.

Methods. We included only those patients who had cultures collected (N=29). Phase 1 of the study lasted for 3 months before implementation of the antibiotic stewardship program. During this phase, pharmacists did not interfere with antibiotic prescribing, but collected data on antibiotics prescribed, duration of therapy, laboratory tests, signs and symptoms of infection, and culture and sensitivity results. Antibiotic use was assessed retrospectively and classified as inappropriate if one or more of several predefined conditions were met, as outlined in Table 1.3,15

Phase 2 of the study lasted for 3 months following the implementation of the antibiotic stewardship program. During this time, pharmacists evaluated the appropriateness of therapy by determining if antibiotic therapy was warranted (if empiric antibiotic choice corresponded with current guidelines). They also received and analyzed culture and sensitivity reports and examined antibiotic dosing for every patient included in phase 2 of the study (N=24). These measures enabled pharmacists to identify areas that required intervention, and they made recommendations by contacting prescribers.

Results. During phase 1 of the antibiotic stewardship program (this was the 3-month period that preceded implementation of the program), we found that 40% of the antibiotics in the nursing home were prescribed inappropriately, supporting the need for the program. Some of the prescriptions met more than one of the criteria for inappropriate antibiotic prescribing (Table 1).

In phase 2 of the study, we found that the involvement of pharmacists resulted in a reduction in inappropriate prescribing of antibiotics from 40% to 21% (about a 50% reduction) within the first 3 months after implementation (Table 2). During this time, pharmacists made 12 interventions recommending changes in antibiotic therapy, all of which were accepted by prescribers.

Discussion

The model for the antibiotic stewardship program that we implemented at the Memorial Health Center Nursing Home consists of a prospective audit and intervention. Antibiotic treatment algorithms and reference charts were created based on current guidelines and other evidence-based sources, to enable staff pharmacists to quickly assess a patient, evaluate the appropriateness of therapy, and offer an alternative if necessary. The infection control coordinator is responsible for updating the antibiogram annually.

Within the first 3 months of implementing the antibiotic stewardship program, the inappropriate use of antibiotics at the nursing home was reduced by 50%. As with any new initiative, the program is being continually evaluated, with modifications expected to improve this result.

Study Limitations

Our study was limited by the small population size and because it was implemented at only one nursing home. In addition, pharmacists were alerted only if a patient’s cultures had been collected. A larger study would be required to demonstrate the impact of antibiotic stewardship programs on LTC resident hospitalization rates and to evaluate the potential economic impact of such a program.

It is also difficult to predict whether our results could be extrapolated to other LTC facilities, because not all facilities have an onsite pharmacy. In such cases, especially when pharmacists do not have access to patients’ medical records, it is likely more difficult to implement an antibiotic stewardship program.

Considerations for Implementing a Successful Pharmacist-Led Program

Pharmacists are medication therapy experts; however, their scope of practice does not include in-depth knowledge of diagnostics or of ordering and interpreting such tests, imaging studies, and other clinical data. For the program to be successful, it must include a physician to offer medical expertise and support as needed, which is in accordance with IDSA recommendations.6,7 Prescribers must also be willing to collaborate with pharmacists to improve antibiotic use.

Access to patient health records and laboratory results may be a challenge if the pharmacy serving a nursing home is located in a different facility and the facilities do not share electronic medical records. Regardless of access to patient records, establishing good communication with nursing staff is essential because nurses are the primary providers of care in nursing homes and typically know more about the residents than anyone else. Securing support from administration is also vital for success. Funding for the program and the institutional policy regarding antibiotic use requires approval from the administration.7

Large-scale research is needed to evaluate the impact of antibiotic stewardship on prescribing practices, patient outcomes, hospitalization rates, and costs of care in LTC facilities, and to compare different program models. Most current recommendations regarding the use of these programs in nursing homes are extrapolated from hospital-based research. Such an approach does not take into consideration the unique aspects and challenges of LTC facilities and is not helpful in developing effective antibiotic stewardship models in these settings.5

The pharmacists at Memorial Health Center have successfully incorporated antibiotic review and monitoring into their daily workflow. After the study results were reviewed by the pharmacy team, it was determined that better follow-up is required to ensure that resistant cultures would not be missed. We plan to continue improving prescribing practices at our nursing home via continuous monitoring of antibiotic use and by assisting prescribers in their choice of antimicrobials.

Conclusion

The inappropriate prescribing of antibiotics is a major problem in US nursing homes, with up to 75% of antibiotics being prescribed inappropriately in this setting.2,3 Unfortunately,
little progress has been made to develop antibiotic stewardship programs in LTC facilities. A pharmacist-led model, such as the one described in this article, could be an effective tool for improving antibiotic use in such settings.

8. US Centers for Disease Control and Prevention. Get smart for healthcare. Impact of antimicrobial stewardship program interventions on antimicrobial resistance. www.cdc.gov/getsmart/healthcare/support-efforts/asp-int-am-resistance.html. Updated November 15, 2010. Accessed July 25, 2012.